The Advisory Committee on Gulf War Veterans has submitted its final report to Gen. Eric K. Shinseki, Secretary of the Department of Veterans Affairs (DVA).
Below is the text of the letter to Gen. Shinseki, the report’s introduction, and a listing of six issue areas. From the Final Report, "Changing the Culture, Placing Care Before Process," dated September 2009:
In April 2008, the Department of Veterans Affairs established the Advisory Committee on Gulf War Veterans to conduct an independent examination of the VA health care and benefits received by Veterans who served in the Southwest Asia Theater of Operations in the Persian Gulf War in 1990-1991 and to provide recommendations on how these Veterans can be better served.
ADVISORY COMMITTEE ON GULF WAR VETERANS
Changing the Culture:
Placing Care Before Process
September 2009
Department of Veterans Affairs
Advisory Committee on Gulf War Veterans
September 29, 2009
The Honorable Eric K. Shinseki
Secretary
Department of Veterans Affairs
810 Vermont Ave, NW
Washington, D.C. 20420
Dear Secretary Shinseki:
On behalf of the Advisory Committee on Gulf War Veterans, I am pleased to submit our final report. With the exception of one dissenting vote relating to the Committee’s recommendation that Gulf War I Veterans be included in the Post Deployment Integrated Care Initiative (PDICI), the report represents the unanimous, collaborative work product of the Committee members.
First, I would like to thank the Department of Veterans Affairs (VA) for giving us the opportunity to assess both the effectiveness of existing benefits and services and to determine the need for new initiatives and policies that pertain exclusively to Gulf War I Veterans. We are honored to participate in your vision of transforming the Department of Veterans Affairs into a 21st century organization while ensuring that the needs of Gulf War I Veterans are met.
The members of the Advisory Committee offered a wide range of perspectives, experiences, and expertise. The body included active duty and retired service members, Veterans of Gulf War I and other conflicts, Veterans Service Organizations’ representatives, medical experts, a widow and family members of Gulf War I service members. We identified six prevailing health care and benefits themes raised during the course of our work: (1) health care priority, (2) access to care, (3) undiagnosed illnesses, (4) classification of Gulf War I records, (5) outreach, and (6) timeliness. The Committee is hopeful that you will carefully consider implementing each of our recommendations and giving Gulf War I Veterans the benefits and services they have earned and rightfully deserve.
We offer our sincere appreciation to your staff at the VA Central Office and throughout the field offices for availing themselves and providing resources as we carried out our charter. We also extend our sincere thanks to the Veterans, Veterans’ advocates and stakeholders, and all who provided their input in this report. Many across the United States traveled to attend the meetings, called into the toll-free teleconference line and wrote letters to the Committee. Finally, we thank all Gulf War I Veterans for their honorable service.
Charles L. Cragin
Chairman
Changing the Culture:
Placing Care Before Process
September 2009
Department of Veterans Affairs
Advisory Committee on Gulf War Veterans
September 29, 2009
The Honorable Eric K. Shinseki
Secretary
Department of Veterans Affairs
810 Vermont Ave, NW
Washington, D.C. 20420
Dear Secretary Shinseki:
On behalf of the Advisory Committee on Gulf War Veterans, I am pleased to submit our final report. With the exception of one dissenting vote relating to the Committee’s recommendation that Gulf War I Veterans be included in the Post Deployment Integrated Care Initiative (PDICI), the report represents the unanimous, collaborative work product of the Committee members.
First, I would like to thank the Department of Veterans Affairs (VA) for giving us the opportunity to assess both the effectiveness of existing benefits and services and to determine the need for new initiatives and policies that pertain exclusively to Gulf War I Veterans. We are honored to participate in your vision of transforming the Department of Veterans Affairs into a 21st century organization while ensuring that the needs of Gulf War I Veterans are met.
The members of the Advisory Committee offered a wide range of perspectives, experiences, and expertise. The body included active duty and retired service members, Veterans of Gulf War I and other conflicts, Veterans Service Organizations’ representatives, medical experts, a widow and family members of Gulf War I service members. We identified six prevailing health care and benefits themes raised during the course of our work: (1) health care priority, (2) access to care, (3) undiagnosed illnesses, (4) classification of Gulf War I records, (5) outreach, and (6) timeliness. The Committee is hopeful that you will carefully consider implementing each of our recommendations and giving Gulf War I Veterans the benefits and services they have earned and rightfully deserve.
We offer our sincere appreciation to your staff at the VA Central Office and throughout the field offices for availing themselves and providing resources as we carried out our charter. We also extend our sincere thanks to the Veterans, Veterans’ advocates and stakeholders, and all who provided their input in this report. Many across the United States traveled to attend the meetings, called into the toll-free teleconference line and wrote letters to the Committee. Finally, we thank all Gulf War I Veterans for their honorable service.
Charles L. Cragin
Chairman
******
INTRODUCTION
Nearly 700,000 troops were deployed to the Persian Gulf region between August 1990 and July 1991. The pace of the buildup for the Gulf War was unprecedented. Within five days after Iraq invaded Kuwait, the United States began moving troops into the region as part of Operation Desert Shield. By September 15, 1990, the number of American service members reached 150,000 and included nearly 50,000 members of the National Guard and Reserve. Within the next month, another 60,000 troops arrived in Southwest Asia; in November, an additional 135,000 Reservists and National Guard members were called up. By February 24, 1991, more than 500,000 United States troops had been deployed to the Persian Gulf region. In addition to the United States troops, a coalition force of 34 member countries was eventually assembled.
The Gulf War reflected many changes from previous wars, particularly in the demographic composition of military personnel and the uncertainty of conditions for many Reservists. Of the nearly 700,000 United States troops who fought in Operation Desert Shield and Operation Desert Storm, almost 7 percent were women and about 17 percent were from National Guard and Reserve units. Military personnel were, overall, older than those who had participated in previous wars with a mean age of 28 years. Seventy percent of the troops were non-Hispanic/White; 23 percent were Black and 5 percent were Hispanic.1 Rapid mobilization exerted substantial pressure on those who were deployed, disrupting lives, separating families, and, for Reserve and National Guard units, creating uncertainty about whether jobs would be available when they returned to civilian life.
Living Conditions
Combat troops were crowded into warehouses and tents on arrival and then often moved to isolated desert locations. Most troops lived in tents and slept on cots lined up side by side, affording virtually no privacy or quiet. Sanitation was often primitive, with strains on latrines and communal washing facilities. Hot showers were infrequent, the interval between laundering uniforms was sometimes long, and desert flies were a constant nuisance, as were scorpions and snakes. Military personnel worked long hours and had narrowly restricted outlets for relaxation. Troops were ordered not to fraternize with local people, and alcoholic drinks were prohibited in deference to religious beliefs in the host countries. A mild, traveler’s type of diarrhea affected more than half of the troops in some units. Fresh fruits and vegetables from neighboring countries were identified as the cause and were removed from the diet. Thereafter, the diet consisted mostly of packaged foods and bottled water.
For the first two months of troop deployment (August and September 1990) the weather was extremely hot and humid, with air temperatures as high as 115°F and sand temperatures reaching 150°F. Except for coastal regions, the relative humidity was less than 40 percent. Troops had to drink large quantities of water to prevent dehydration. Although the summers were hot and dry, temperatures in winter (December – March) were low, with wind-chill temperatures at night dropping to well below freezing. Wind and blowing sand made protection of skin and eyes imperative. Goggles and sunglasses helped somewhat, but visibility was often poor.
Environmental and Chemical Exposures
The most visually dramatic environmental event of the Gulf War was the smoke from more than 750 oil-well fires. Smoke plumes from individual fires rose and combined to form giant plumes that could be seen for hundreds of kilometers. There were additional potential sources of exposure to petroleum-based combustion products. Kerosene, diesel, and leaded gasoline were used in unvented tent heaters, cooking stoves, and portable generators. Exposures to tent-heater emissions were not specifically documented, but a simulation study was conducted after the war to determine exposure. Petroleum products, including diesel fuels, were also used to suppress sand and dust, and petroleum fuels were used to aid in the burning of waste and trash.
Pesticides were widely used by troops in the Persian Gulf to combat the region’s ubiquitous insect and rodent populations; and although guidelines for use were strict, there were many reports of misuse. Indeed, many troops wore dog flea collars for personal insect deterrence. The pesticides used included methyl carbamates, organophosphates, pyrethroids, and chlorinated hydrocarbons. The use of those pesticides is reported in numerous reports; however, objective information regarding individual levels of pesticide exposure is generally not available.
Many exposures could have been related to particular occupational activities in the Gulf War. The majority of occupational chemical exposures appear to have been related to aircraft operations (jet fuel, hydraulic fluid, and lubricants), repair and maintenance activities, including battery repair (corrosive liquids), cleaning and degreasing (solvents, including chlorinated hydrocarbons), sandblasting (abrasive particles), vehicle repair (asbestos, carbon monoxide, and organic solvents), weapon repair (lead particles), and welding and cutting (chromates, nitrogen dioxide, and heated metal fumes). In addition, troops painted vehicles and other equipment used in the gulf with a chemical-agent resistant coating either before being shipped to the gulf or at ports in Saudi Arabia. Working conditions in the field were not ideal and recommended occupational-hygiene standards might not have been followed at all times.
Exposure of United States personnel to depleted uranium (DU) occurred as the result of "friendly fire" incidents, cleanup operations, and accidents (including fires). Others might have inhaled DU dust through contact with DU-contaminated tanks or munitions.
Threat of Chemical and Biologic Warfare
When United States troops arrived in the gulf, they had no way of knowing whether they would be exposed to biologic and chemical weapons. Iraq previously had used such weapons in fighting Iran and in attacks on the Kurdish minority in Iraq. Military leaders feared that the use of such weapons in the gulf could result in the deaths of tens of thousands of Americans. Therefore, in addition to the standard vaccinations before military deployment, about 150,000 troops received anthrax vaccine and about 8,000 botulinum toxoid vaccine. In some cases, vaccination records were kept, and they provide an objective measure of exposure in addition to self-reporting by troops.
Troops were also given blister packs of 21 tablets of Pyridostigmine Bromide (PB) to protect against agents of chemical warfare, specifically nerve gas. Troops were to take PB as a precaution against a chemical-warfare attack. Chemical sensors and alarms were distributed throughout the region to warn of such attacks. The alarms were extremely sensitive and could be triggered by many substances, including some organic solvents, vehicle-exhaust fumes, and insecticides. Alarms sounded often and troops responded by donning the confining protective gear and ingesting PB as an antidote to nerve gas. In addition to the alarms, there were widespread reports of dead sheep, goats, and camels, which troops were taught could be an indication of the use of chemical or biologic weapons. The sounding of the alarms, the reports of dead animals, and rumors that other units had been hit by chemical warfare agents caused the troops to be concerned that they would be or had been exposed to such agents.
Despite the small numbers of United States personnel injured or killed during combat in the Gulf War, the troops, as in any war, faced the fear of death, injury, or capture by the enemy. After the war, there was the potential for other exposures, including United States demolition of a munitions storage complex at Khamisiyah, Iraq, which – unbeknownst to demolition troops at the time – contained stores of Sarin and cyclosarin.
It has been documented from the Civil War to the Gulf War that a variety of physical and psychological stressors have placed military personnel at a potentially higher risk for adverse health effects. In addition to the threat or experience of combat, the Gulf War involved rapid and unexpected deployment, harsh living conditions, and anticipation of exposure to chemical and biologic agents, environmental pollution from burning oil fires, and family disruption and financial strain.2
Gulf War I Stressors – Chemical-Biological (CB) Threat and False Alarms
Veterans who deployed to Saudi Arabia in support of Operations Desert Shield and Desert Storm from 1990 – 1991 (herein referred to as “Gulf War I”) were exposed to a wide variety of stressors. However, what seems to have been forgotten is that stressors of war evolve over the time line of many different war experiences: pre-deployment, deployment, sustainment, hostilities, reunion and reintegration. During Gulf War I, American forces sustained 148 combat dead, 145 non-battle deaths, 21 prisoners of war and 467 wounded in action.3 The forecasts had been for tens of thousands of deaths, and for chemical and biological warfare attacks. During the weeks leading up to ground combat, there were frequent alarms for chemical attacks and Scud missile attacks. The former were virtually always false alarms, but they were powerful stressors nonetheless.
As service members entered ground combat, they had no way of knowing that there would be no massive Iraqi chemical attack and that the combat would be a very lopsided contest. To them, this was an extremely dangerous operation with a high risk of death and injury.
Throughout history Veterans have been reluctant to acknowledge injury, physical or mental, as a result of their service. For Veterans of Gulf War I and prior conflicts, it was their responsibility to self-identify problems or symptoms and there are many reasons they may have been reluctant to do so. Veterans may not appreciate or recognize the seriousness of the condition; they may see it as a sign of weakness having been taught to simply “suck it up” and fight through it alone; they believe others are more deserving; their training doesn’t encourage them to get in touch with their feelings; they may perceive a level of stigma or fear it will harm their careers, both military and civilian. These attitudes are especially disturbing in Veterans who have been exposed to combat, trauma, violence and death, and are at an elevated risk for mental health illnesses like Post Traumatic Stress Disorder (PTSD). This is an unfortunate byproduct of the military culture that leads to missed or undiagnosed illnesses that affect them for the rest of their lives. Consequently, VA medical and disability benefits are often ignored.
Fortunately, PTSD is recognized by today’s military leaders and they are working to reduce the stigma associated with the disorder. All services are educating members about PTSD and what to look for in themselves and other service members. Additionally, the military is integrating mental health care into the general health care process. Leaders reinforce to service members that it is not a sign of weakness and that it is their duty to seek out treatment. Unfortunately, thousands of Veterans with mental health issues from Gulf War I and prior conflicts are still suffering because they have fallen victim to the attitudes or stigmas of the past, or a Department of Veterans Affairs’ (VA) bureaucracy focused on physical versus mental injuries.
In addition, there has been a neurological link to a diagnosis of Amyotrophic Lateral Sclerosis (ALS), a disease of motor neurons, to service in the Gulf War. Multiple Sclerosis (MS), a disease of the white matter of the brain, is under investigation by the VA as a potential association with service in the Gulf War. Other neurobiological studies are ongoing seeking to establish a biologic basis for the symptoms expressed in Gulf War illnesses.
The Establishment and Tasking of Advisory Committee on Gulf War Veterans
In April 2008, the Department of Veterans Affairs established the Advisory Committee on Gulf War Veterans to conduct an independent examination of the VA health care and benefits received by Veterans who served in the Southwest Asia Theater of Operations in the Persian Gulf War in 1990-1991 and to provide recommendations on how these Veterans can be better served.
Members of the Committee were selected to provide a broad range of perspectives, experiences and expertise. The Committee includes active duty and retired service members; Veterans of Gulf War I and other conflicts; Veterans Service Organizations’ representatives; medical experts; and the widow of a Gulf War I service member. The Committee membership and biographies can be found at Appendix A.
Committee Activities
Due to the lack of reliable data concerning this population, the Committee was forced to base the majority of its findings on scattered scientific research and anecdotal information. Because of the reliance on such information, the Committee took extra efforts to contact Veterans (both users of VA services and those who did not use VA services) to come before the Committee and report on their personal experiences. The Committee, also in an effort to open communications, broadcasted its meetings via toll free telephone lines, maintained a Committee website with meeting minutes and presentations, and accepted and distributed written testimony from Veterans and family members who could not attend the meetings in person. The Committee held eight public meetings in Washington, DC; Baltimore, MD; Seattle, WA; and Atlanta, GA.
The Committee met with subject matter experts from the Veterans Health Administration (VHA), Veterans Benefits Administration (VBA), National Cemetery Administration (NCA), Board of Veterans’ Appeals (BVA), various VA staff offices, the Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC), the Centers for Disease Control and Prevention, researchers from the University of Texas Southwestern Medical Center, Veterans Service Organizations, and various State Departments of Veterans Affairs, as well as representatives of the National Guard and Reserves. In addition, the Committee spoke with Veterans and Veterans’ family members and received testimony from members of the public at each meeting. Appendix C contains the agendas and locations of each meeting. Appendix D summarizes guest presenters, Gulf War I Veteran panel members, Veterans and other interested parties who communicated with the Advisory Committee on Gulf War Veterans during the public comment periods.
A Generation Later
“Concerns about Gulf War-related health consequences and higher rates of cause-specific mortality continue to persist 18 years after the conflict.”4 These brave men and women answered our nation’s call to arms in the first large-scale military mobilization since the Vietnam War. Many of these patriots came from communities across the country as members of the Reserves and National Guard, and upon completion of their honorable military service in a hostile theater of operations, some turned to the VA for help. Some Gulf War I Veterans reported medical conditions which were not properly understood or addressed by health care professionals within VA. Some of these Veterans were falsely accused of malingering and diagnosed as simply “stressed out” over the recent deployment. The majority of the reported symptoms would have prevented deployment and clearly limited job performance capabilities. In many cases, these Veterans believed that their honor and personal integrity were challenged by the very professionals entrusted with their health care.
The search for the scientific cause for these complex and unexplained medical conditions hindered the timely and proper care and treatment of this complex of symptoms commonly referred to as Gulf War Illness. When Gulf War I Veterans sought VA care and services, many in the VA community were defensive and reactive. This meant Veterans often did not receive the benefit of the doubt or timely access to quality health care and services. Many Veterans were understandably dissatisfied with the way they were treated and withdrew from the VA community frustrated and more importantly, with many unanswered health questions.
The health risks of Gulf War I Veterans have been and still are a serious challenge to VA. In the words of the Institute of Medicine (IOM), “Every study reviewed by this Committee found that Veterans of the Gulf War report higher rates of nearly all symptoms examined than their non-deployed counterparts.”5 The challenge to the VA is heightened because the number of Gulf War I Veterans with such symptoms is very large and these symptoms have persisted. The IOM noted that the largest and most nationally representative survey of United States Veterans found that nearly 29 percent of deployed Veterans met a case definition of “multi-symptom illnesses” and for many Gulf War I Veterans this remains an unexplained and undiagnosed illness. VA physicians have great difficulty in confirming or categorizing illnesses in these Veterans and are not able to follow through effectively with treatment and care. The Committee heard testimony from many Veterans and researchers suggesting that these symptoms have had an ongoing, limiting and in many instances disabling effect on ability to function in civilian life. Furthermore, testimony to the Committee from Dr. Han Kang, Dr. Robert Haley and others, as well as testimony from many Veterans, suggests that for many of these Veterans, their problems are chronic. In short, as summarized in a 2009 study by the Department of Veterans Affairs, “1991 Gulf War Veterans continue to report a higher prevalence of many adverse health outcomes, both physical and mental, compared with Gulf era Veterans.”6 Because of the non-specificity of their symptoms, Gulf War I Veterans have had a limited and in many ways ineffective response from the VA system.
Another major challenge in dealing effectively with the health issues of Gulf War I Veterans has been the difficulty of establishing a definitive cause for the reported health problems. Gulf War I is unique because of the multiplicity of environmental factors potentially affecting those who served at that time. The Committee notes that the Research Advisory Committee on Gulf War Veterans Illnesses has recently opined that two of these factors, Pyridostigmine Bromide and pesticides, are causally linked to the development of illness in these Veterans. This opinion will undoubtedly be thoroughly reviewed and assessed by VA and others. Regardless of the outcome of that review, the fact that 18 years later we are still assessing this wide array of environmental hazards and still debating which ones might be causally related to illness in this group of Veterans has further constrained an effective response to the health issues of Gulf War I Veterans.
Although there have been many advances which have occurred in the health programs at the Department of Defense (DOD) and VA in recent years, Gulf War I Veterans unfortunately preceded these advances and have not fully benefitted from them.
The Committee has found that VA’s processes often prevent the effective and timely delivery of care and benefits to Gulf War I Veterans. The process creates impediments – like the experience with undiagnosed illness. Testimony from Veterans highlighted the frustrations of navigating the VA system and the inability to have their undiagnosed illnesses addressed. Newer approaches to more systematic health evaluation of service members’ pre- and post-deployment and newer approaches to more effectively organizing and integrating care and benefits for Veterans with health problems have been very beneficial for Veterans of more recent conflicts, but have not been inclusive of Gulf War I Veterans. There is a clear need to move beyond the somewhat narrow and restrictive confines of treating diagnosable illness to addressing the broader functional limitations which remain as ongoing problems requiring health and social interventions.
Over the course of our proceedings, several recurring health care and benefit themes emerged which confront Gulf War I Veterans. This report groups these themes into six issue categories:
Issue 1: Health Care Priority for Gulf War I Veterans
Issue 2: Access to and Quality of Care for Gulf War I Veterans
Issue 3: Undiagnosed Illnesses
Issue 4: Identification of Gulf War I Veterans in VA Records
Issue 5: Outreach
Issue 6: Timeliness of Communications
The Committee has worked to present recommendations that are people-centric, results oriented, and forward-looking, in keeping with Secretary Shinseki’s announced priorities for the transformation of the Department of Veterans Affairs. Our goal is to improve access to VA benefits and health care services for Veterans of Gulf War I.
1 SC Joseph, “A Comprehensive Clinical Evaluation of 20,000 Persian Gulf War Veterans” Mil Med
162(3): 149-155 (1997).
2 Portions of the Introduction are adapted from Carolyn E. Fulco, ed., Gulf War and Health, Volume 1,
Institutes of Medicine, (2000).
3 Robert Gifford, Robert Ursano, John Stuart, & Charles Engle, “Stress and Stressors of the Early Phases of
the Persian Gulf War,” Philosophical Transactions of The Royal Society 361(1468): 585-591 (2006).
4 Shannon K. Barth, MPH , Han K. Kang, DrPH , Tim A. Bullman, MS, Mitchell T. Wallin, MD, MPH,
“Neurological Mortality Among U.S. Veterans of the Persian Gulf War: 13-Year Follow-up,” American
Journal of Industrial Medicine 52(9):663-70 (2009).
5 Gulf War and Health, Volume 4, pages 2 – 3 (2006).
6 Kang, Han K. DrPH; Li, Bo MA; Mahan, Clare M. PhD; Eisen, Seth A. MD, MSc; Engel, Charles C.
MD, MPH, “Health of US Veterans of 1991 Gulf War: A Follow-Up Survey in 10 Years,” Journal of
Occupational and Environmental Medicine 51(4): 401-410 (2009).
Nearly 700,000 troops were deployed to the Persian Gulf region between August 1990 and July 1991. The pace of the buildup for the Gulf War was unprecedented. Within five days after Iraq invaded Kuwait, the United States began moving troops into the region as part of Operation Desert Shield. By September 15, 1990, the number of American service members reached 150,000 and included nearly 50,000 members of the National Guard and Reserve. Within the next month, another 60,000 troops arrived in Southwest Asia; in November, an additional 135,000 Reservists and National Guard members were called up. By February 24, 1991, more than 500,000 United States troops had been deployed to the Persian Gulf region. In addition to the United States troops, a coalition force of 34 member countries was eventually assembled.
The Gulf War reflected many changes from previous wars, particularly in the demographic composition of military personnel and the uncertainty of conditions for many Reservists. Of the nearly 700,000 United States troops who fought in Operation Desert Shield and Operation Desert Storm, almost 7 percent were women and about 17 percent were from National Guard and Reserve units. Military personnel were, overall, older than those who had participated in previous wars with a mean age of 28 years. Seventy percent of the troops were non-Hispanic/White; 23 percent were Black and 5 percent were Hispanic.1 Rapid mobilization exerted substantial pressure on those who were deployed, disrupting lives, separating families, and, for Reserve and National Guard units, creating uncertainty about whether jobs would be available when they returned to civilian life.
Living Conditions
Combat troops were crowded into warehouses and tents on arrival and then often moved to isolated desert locations. Most troops lived in tents and slept on cots lined up side by side, affording virtually no privacy or quiet. Sanitation was often primitive, with strains on latrines and communal washing facilities. Hot showers were infrequent, the interval between laundering uniforms was sometimes long, and desert flies were a constant nuisance, as were scorpions and snakes. Military personnel worked long hours and had narrowly restricted outlets for relaxation. Troops were ordered not to fraternize with local people, and alcoholic drinks were prohibited in deference to religious beliefs in the host countries. A mild, traveler’s type of diarrhea affected more than half of the troops in some units. Fresh fruits and vegetables from neighboring countries were identified as the cause and were removed from the diet. Thereafter, the diet consisted mostly of packaged foods and bottled water.
For the first two months of troop deployment (August and September 1990) the weather was extremely hot and humid, with air temperatures as high as 115°F and sand temperatures reaching 150°F. Except for coastal regions, the relative humidity was less than 40 percent. Troops had to drink large quantities of water to prevent dehydration. Although the summers were hot and dry, temperatures in winter (December – March) were low, with wind-chill temperatures at night dropping to well below freezing. Wind and blowing sand made protection of skin and eyes imperative. Goggles and sunglasses helped somewhat, but visibility was often poor.
Environmental and Chemical Exposures
The most visually dramatic environmental event of the Gulf War was the smoke from more than 750 oil-well fires. Smoke plumes from individual fires rose and combined to form giant plumes that could be seen for hundreds of kilometers. There were additional potential sources of exposure to petroleum-based combustion products. Kerosene, diesel, and leaded gasoline were used in unvented tent heaters, cooking stoves, and portable generators. Exposures to tent-heater emissions were not specifically documented, but a simulation study was conducted after the war to determine exposure. Petroleum products, including diesel fuels, were also used to suppress sand and dust, and petroleum fuels were used to aid in the burning of waste and trash.
Pesticides were widely used by troops in the Persian Gulf to combat the region’s ubiquitous insect and rodent populations; and although guidelines for use were strict, there were many reports of misuse. Indeed, many troops wore dog flea collars for personal insect deterrence. The pesticides used included methyl carbamates, organophosphates, pyrethroids, and chlorinated hydrocarbons. The use of those pesticides is reported in numerous reports; however, objective information regarding individual levels of pesticide exposure is generally not available.
Many exposures could have been related to particular occupational activities in the Gulf War. The majority of occupational chemical exposures appear to have been related to aircraft operations (jet fuel, hydraulic fluid, and lubricants), repair and maintenance activities, including battery repair (corrosive liquids), cleaning and degreasing (solvents, including chlorinated hydrocarbons), sandblasting (abrasive particles), vehicle repair (asbestos, carbon monoxide, and organic solvents), weapon repair (lead particles), and welding and cutting (chromates, nitrogen dioxide, and heated metal fumes). In addition, troops painted vehicles and other equipment used in the gulf with a chemical-agent resistant coating either before being shipped to the gulf or at ports in Saudi Arabia. Working conditions in the field were not ideal and recommended occupational-hygiene standards might not have been followed at all times.
Exposure of United States personnel to depleted uranium (DU) occurred as the result of "friendly fire" incidents, cleanup operations, and accidents (including fires). Others might have inhaled DU dust through contact with DU-contaminated tanks or munitions.
Threat of Chemical and Biologic Warfare
When United States troops arrived in the gulf, they had no way of knowing whether they would be exposed to biologic and chemical weapons. Iraq previously had used such weapons in fighting Iran and in attacks on the Kurdish minority in Iraq. Military leaders feared that the use of such weapons in the gulf could result in the deaths of tens of thousands of Americans. Therefore, in addition to the standard vaccinations before military deployment, about 150,000 troops received anthrax vaccine and about 8,000 botulinum toxoid vaccine. In some cases, vaccination records were kept, and they provide an objective measure of exposure in addition to self-reporting by troops.
Troops were also given blister packs of 21 tablets of Pyridostigmine Bromide (PB) to protect against agents of chemical warfare, specifically nerve gas. Troops were to take PB as a precaution against a chemical-warfare attack. Chemical sensors and alarms were distributed throughout the region to warn of such attacks. The alarms were extremely sensitive and could be triggered by many substances, including some organic solvents, vehicle-exhaust fumes, and insecticides. Alarms sounded often and troops responded by donning the confining protective gear and ingesting PB as an antidote to nerve gas. In addition to the alarms, there were widespread reports of dead sheep, goats, and camels, which troops were taught could be an indication of the use of chemical or biologic weapons. The sounding of the alarms, the reports of dead animals, and rumors that other units had been hit by chemical warfare agents caused the troops to be concerned that they would be or had been exposed to such agents.
Despite the small numbers of United States personnel injured or killed during combat in the Gulf War, the troops, as in any war, faced the fear of death, injury, or capture by the enemy. After the war, there was the potential for other exposures, including United States demolition of a munitions storage complex at Khamisiyah, Iraq, which – unbeknownst to demolition troops at the time – contained stores of Sarin and cyclosarin.
It has been documented from the Civil War to the Gulf War that a variety of physical and psychological stressors have placed military personnel at a potentially higher risk for adverse health effects. In addition to the threat or experience of combat, the Gulf War involved rapid and unexpected deployment, harsh living conditions, and anticipation of exposure to chemical and biologic agents, environmental pollution from burning oil fires, and family disruption and financial strain.2
Gulf War I Stressors – Chemical-Biological (CB) Threat and False Alarms
Veterans who deployed to Saudi Arabia in support of Operations Desert Shield and Desert Storm from 1990 – 1991 (herein referred to as “Gulf War I”) were exposed to a wide variety of stressors. However, what seems to have been forgotten is that stressors of war evolve over the time line of many different war experiences: pre-deployment, deployment, sustainment, hostilities, reunion and reintegration. During Gulf War I, American forces sustained 148 combat dead, 145 non-battle deaths, 21 prisoners of war and 467 wounded in action.3 The forecasts had been for tens of thousands of deaths, and for chemical and biological warfare attacks. During the weeks leading up to ground combat, there were frequent alarms for chemical attacks and Scud missile attacks. The former were virtually always false alarms, but they were powerful stressors nonetheless.
As service members entered ground combat, they had no way of knowing that there would be no massive Iraqi chemical attack and that the combat would be a very lopsided contest. To them, this was an extremely dangerous operation with a high risk of death and injury.
Throughout history Veterans have been reluctant to acknowledge injury, physical or mental, as a result of their service. For Veterans of Gulf War I and prior conflicts, it was their responsibility to self-identify problems or symptoms and there are many reasons they may have been reluctant to do so. Veterans may not appreciate or recognize the seriousness of the condition; they may see it as a sign of weakness having been taught to simply “suck it up” and fight through it alone; they believe others are more deserving; their training doesn’t encourage them to get in touch with their feelings; they may perceive a level of stigma or fear it will harm their careers, both military and civilian. These attitudes are especially disturbing in Veterans who have been exposed to combat, trauma, violence and death, and are at an elevated risk for mental health illnesses like Post Traumatic Stress Disorder (PTSD). This is an unfortunate byproduct of the military culture that leads to missed or undiagnosed illnesses that affect them for the rest of their lives. Consequently, VA medical and disability benefits are often ignored.
Fortunately, PTSD is recognized by today’s military leaders and they are working to reduce the stigma associated with the disorder. All services are educating members about PTSD and what to look for in themselves and other service members. Additionally, the military is integrating mental health care into the general health care process. Leaders reinforce to service members that it is not a sign of weakness and that it is their duty to seek out treatment. Unfortunately, thousands of Veterans with mental health issues from Gulf War I and prior conflicts are still suffering because they have fallen victim to the attitudes or stigmas of the past, or a Department of Veterans Affairs’ (VA) bureaucracy focused on physical versus mental injuries.
In addition, there has been a neurological link to a diagnosis of Amyotrophic Lateral Sclerosis (ALS), a disease of motor neurons, to service in the Gulf War. Multiple Sclerosis (MS), a disease of the white matter of the brain, is under investigation by the VA as a potential association with service in the Gulf War. Other neurobiological studies are ongoing seeking to establish a biologic basis for the symptoms expressed in Gulf War illnesses.
The Establishment and Tasking of Advisory Committee on Gulf War Veterans
In April 2008, the Department of Veterans Affairs established the Advisory Committee on Gulf War Veterans to conduct an independent examination of the VA health care and benefits received by Veterans who served in the Southwest Asia Theater of Operations in the Persian Gulf War in 1990-1991 and to provide recommendations on how these Veterans can be better served.
Members of the Committee were selected to provide a broad range of perspectives, experiences and expertise. The Committee includes active duty and retired service members; Veterans of Gulf War I and other conflicts; Veterans Service Organizations’ representatives; medical experts; and the widow of a Gulf War I service member. The Committee membership and biographies can be found at Appendix A.
Committee Activities
Due to the lack of reliable data concerning this population, the Committee was forced to base the majority of its findings on scattered scientific research and anecdotal information. Because of the reliance on such information, the Committee took extra efforts to contact Veterans (both users of VA services and those who did not use VA services) to come before the Committee and report on their personal experiences. The Committee, also in an effort to open communications, broadcasted its meetings via toll free telephone lines, maintained a Committee website with meeting minutes and presentations, and accepted and distributed written testimony from Veterans and family members who could not attend the meetings in person. The Committee held eight public meetings in Washington, DC; Baltimore, MD; Seattle, WA; and Atlanta, GA.
The Committee met with subject matter experts from the Veterans Health Administration (VHA), Veterans Benefits Administration (VBA), National Cemetery Administration (NCA), Board of Veterans’ Appeals (BVA), various VA staff offices, the Research Advisory Committee on Gulf War Veterans’ Illnesses (RAC), the Centers for Disease Control and Prevention, researchers from the University of Texas Southwestern Medical Center, Veterans Service Organizations, and various State Departments of Veterans Affairs, as well as representatives of the National Guard and Reserves. In addition, the Committee spoke with Veterans and Veterans’ family members and received testimony from members of the public at each meeting. Appendix C contains the agendas and locations of each meeting. Appendix D summarizes guest presenters, Gulf War I Veteran panel members, Veterans and other interested parties who communicated with the Advisory Committee on Gulf War Veterans during the public comment periods.
A Generation Later
“Concerns about Gulf War-related health consequences and higher rates of cause-specific mortality continue to persist 18 years after the conflict.”4 These brave men and women answered our nation’s call to arms in the first large-scale military mobilization since the Vietnam War. Many of these patriots came from communities across the country as members of the Reserves and National Guard, and upon completion of their honorable military service in a hostile theater of operations, some turned to the VA for help. Some Gulf War I Veterans reported medical conditions which were not properly understood or addressed by health care professionals within VA. Some of these Veterans were falsely accused of malingering and diagnosed as simply “stressed out” over the recent deployment. The majority of the reported symptoms would have prevented deployment and clearly limited job performance capabilities. In many cases, these Veterans believed that their honor and personal integrity were challenged by the very professionals entrusted with their health care.
The search for the scientific cause for these complex and unexplained medical conditions hindered the timely and proper care and treatment of this complex of symptoms commonly referred to as Gulf War Illness. When Gulf War I Veterans sought VA care and services, many in the VA community were defensive and reactive. This meant Veterans often did not receive the benefit of the doubt or timely access to quality health care and services. Many Veterans were understandably dissatisfied with the way they were treated and withdrew from the VA community frustrated and more importantly, with many unanswered health questions.
The health risks of Gulf War I Veterans have been and still are a serious challenge to VA. In the words of the Institute of Medicine (IOM), “Every study reviewed by this Committee found that Veterans of the Gulf War report higher rates of nearly all symptoms examined than their non-deployed counterparts.”5 The challenge to the VA is heightened because the number of Gulf War I Veterans with such symptoms is very large and these symptoms have persisted. The IOM noted that the largest and most nationally representative survey of United States Veterans found that nearly 29 percent of deployed Veterans met a case definition of “multi-symptom illnesses” and for many Gulf War I Veterans this remains an unexplained and undiagnosed illness. VA physicians have great difficulty in confirming or categorizing illnesses in these Veterans and are not able to follow through effectively with treatment and care. The Committee heard testimony from many Veterans and researchers suggesting that these symptoms have had an ongoing, limiting and in many instances disabling effect on ability to function in civilian life. Furthermore, testimony to the Committee from Dr. Han Kang, Dr. Robert Haley and others, as well as testimony from many Veterans, suggests that for many of these Veterans, their problems are chronic. In short, as summarized in a 2009 study by the Department of Veterans Affairs, “1991 Gulf War Veterans continue to report a higher prevalence of many adverse health outcomes, both physical and mental, compared with Gulf era Veterans.”6 Because of the non-specificity of their symptoms, Gulf War I Veterans have had a limited and in many ways ineffective response from the VA system.
Another major challenge in dealing effectively with the health issues of Gulf War I Veterans has been the difficulty of establishing a definitive cause for the reported health problems. Gulf War I is unique because of the multiplicity of environmental factors potentially affecting those who served at that time. The Committee notes that the Research Advisory Committee on Gulf War Veterans Illnesses has recently opined that two of these factors, Pyridostigmine Bromide and pesticides, are causally linked to the development of illness in these Veterans. This opinion will undoubtedly be thoroughly reviewed and assessed by VA and others. Regardless of the outcome of that review, the fact that 18 years later we are still assessing this wide array of environmental hazards and still debating which ones might be causally related to illness in this group of Veterans has further constrained an effective response to the health issues of Gulf War I Veterans.
Although there have been many advances which have occurred in the health programs at the Department of Defense (DOD) and VA in recent years, Gulf War I Veterans unfortunately preceded these advances and have not fully benefitted from them.
The Committee has found that VA’s processes often prevent the effective and timely delivery of care and benefits to Gulf War I Veterans. The process creates impediments – like the experience with undiagnosed illness. Testimony from Veterans highlighted the frustrations of navigating the VA system and the inability to have their undiagnosed illnesses addressed. Newer approaches to more systematic health evaluation of service members’ pre- and post-deployment and newer approaches to more effectively organizing and integrating care and benefits for Veterans with health problems have been very beneficial for Veterans of more recent conflicts, but have not been inclusive of Gulf War I Veterans. There is a clear need to move beyond the somewhat narrow and restrictive confines of treating diagnosable illness to addressing the broader functional limitations which remain as ongoing problems requiring health and social interventions.
Over the course of our proceedings, several recurring health care and benefit themes emerged which confront Gulf War I Veterans. This report groups these themes into six issue categories:
Issue 1: Health Care Priority for Gulf War I Veterans
Issue 2: Access to and Quality of Care for Gulf War I Veterans
Issue 3: Undiagnosed Illnesses
Issue 4: Identification of Gulf War I Veterans in VA Records
Issue 5: Outreach
Issue 6: Timeliness of Communications
The Committee has worked to present recommendations that are people-centric, results oriented, and forward-looking, in keeping with Secretary Shinseki’s announced priorities for the transformation of the Department of Veterans Affairs. Our goal is to improve access to VA benefits and health care services for Veterans of Gulf War I.
1 SC Joseph, “A Comprehensive Clinical Evaluation of 20,000 Persian Gulf War Veterans” Mil Med
162(3): 149-155 (1997).
2 Portions of the Introduction are adapted from Carolyn E. Fulco, ed., Gulf War and Health, Volume 1,
Institutes of Medicine, (2000).
3 Robert Gifford, Robert Ursano, John Stuart, & Charles Engle, “Stress and Stressors of the Early Phases of
the Persian Gulf War,” Philosophical Transactions of The Royal Society 361(1468): 585-591 (2006).
4 Shannon K. Barth, MPH , Han K. Kang, DrPH , Tim A. Bullman, MS, Mitchell T. Wallin, MD, MPH,
“Neurological Mortality Among U.S. Veterans of the Persian Gulf War: 13-Year Follow-up,” American
Journal of Industrial Medicine 52(9):663-70 (2009).
5 Gulf War and Health, Volume 4, pages 2 – 3 (2006).
6 Kang, Han K. DrPH; Li, Bo MA; Mahan, Clare M. PhD; Eisen, Seth A. MD, MSc; Engel, Charles C.
MD, MPH, “Health of US Veterans of 1991 Gulf War: A Follow-Up Survey in 10 Years,” Journal of
Occupational and Environmental Medicine 51(4): 401-410 (2009).
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